Devices & Lines

The patient has arrived with a device nobody in the department has handled before. What it is, what goes wrong with it, what you do in the first ten minutes, and who to call.

Airway

• Ambulatory chest drain / pneumothorax device

  A patient sent home with a small chest device for a pneumothorax comes back. Check the one-way valve and, above all, exclude a tension pneumothorax.

• Home oxygen

  A patient on home oxygen is usually at risk of hypercapnia. The danger in the ED is giving them too much, not too little.

• Home ventilation (domiciliary NIV / cough assist)

  A patient already on long-term ventilatory support arrives acutely unwell. Their baseline gases are abnormal by design - treat the change, not the number.

• Laryngectomy stoma

  The neck stoma is the only airway. Nothing you do at the mouth or nose reaches the lungs.

• Tracheo-oesophageal puncture (TEP) voice prosthesis

  A one-way valve that lets a laryngectomy patient speak. In an emergency it is left alone - pulling it out helps nothing and opens a tract into the oesophagus.

• Tracheostomy

  There are two airways, not one. Unlike a laryngectomy, the mouth may still work - so oxygen goes on BOTH the face and the stoma.

Cardiac & circulatory support

• CRT and subcutaneous ICD (where they differ)

  Variants of the pacemaker/ICD, read against that page. CRT-D and S-ICD shock; CRT-P does not. A CRT-P is a pacemaker and a magnet will not switch it off.

• Implantable loop recorder

  It only records - it delivers no therapy and is almost never the emergency. The point of this entry is to stop it distracting you.

• LVAD / ventricular assist device

  No pulse, no cuff reading, no useful sats - and that can all be normal. Decide on perfusion, not on a pulse, and call the VAD centre immediately.

• Pacemaker and ICD

  The question that changes everything is whether the box can shock. A magnet does opposite things to a pacemaker and to an ICD - so find out which one it is first.

Vascular access & dialysis

• Haemodialysis fistula and graft

  The dialysis patient's lifeline in the arm. Protect it: no BP, no bloods, no cannula in that arm. Bleeding can be fatal, and a lost thrill is an emergency.

• Implanted port (port-a-cath)

  A central line buried entirely under the skin. You access it only with a non-coring (Huber) needle and strict asepsis - and only if trained. The disc is the clue.

• Intraosseous access (already sited)

  Emergency access drilled into bone, often sited prehospital. It works for everything IV - but it comes out within 24 hours and compartment syndrome is the thing to watch.

• PICC and midline

  A long catheter in an arm vein, usually for antibiotics or chemo. Fever means think line infection; a swollen arm means think line thrombosis. Don't pull it reflexively.

• Peritoneal dialysis catheter

  A soft tube into the abdomen for peritoneal dialysis. A cloudy bag is PD peritonitis until proven otherwise - send the effluent, call renal, and don't delay antibiotics.

• Tunnelled central line (Hickman)

  A long-term central line tunnelled under the chest skin, usually for chemo or TPN. The default assumption in a febrile patient is that the line is infected - but prove it and don't reflexively remove it.

• Tunnelled dialysis catheter

  A large-bore chest line that is the patient's dialysis lifeline. Fever = assume line infection until proven otherwise - and it is not for your routine bloods or drugs.

GI & nutrition

• Balloon gastrostomy and button

  A gastrostomy held in by a water-filled balloon, not a bumper - so it can be replaced through the tract at the bedside. The 3am point: confirm position before feeding, and keep the tract open.

• Gastrostomy (PEG / RIG)

  A feeding tube through the abdominal wall into the stomach. The two that bite in the ED: a dislodged tube (the tract closes in hours) and a buried bumper (pain on feeding).

• Nasogastric / nasojejunal tube (and nasal bridle)

  A feeding tube down the nose. Feeding one in the wrong place - the lung - is a Never Event. Before anything goes down it, confirm the tip with pH (1-5.5) or x-ray; a bridle holds the tube but does not confirm where it is.

• Oesophageal stent

  A self-expanding tube holding the gullet open, almost always to palliate cancer dysphagia. The ED problems: it blocks (often with food), it can migrate, and chest pain after one may be a perforation.

• Stoma: ileostomy and colostomy

  A piece of bowel brought to the skin to divert stool. The ED problems: a high-output stoma dehydrating the patient, obstruction (the stoma stops working), and a dusky or black stoma, which is ischaemia.

Urinary

• Ileal conduit (urostomy)

  A urine-draining stoma made from a short piece of bowel, usually after bladder removal for cancer. The ED problems: no urine from the stoma means obstruction, and infection means pyelonephritis, not a bladder UTI.

• Nephrostomy tube

  A tube draining urine directly from the kidney through the back, placed because the ureter is blocked. If it blocks or falls out, the obstruction returns - and an obstructed, infected kidney is a sepsis emergency.

• Suprapubic catheter

  A catheter into the bladder through the lower abdomen. The 3am fact: if it falls out, the track closes within hours - replace it fast - and a fresh one blocking in the first weeks must not be forced.

• Ureteric stent (JJ stent)

  An internal tube running from kidney to bladder to keep the ureter open. The ED problems: stent symptoms that mimic a UTI, infection in a stented system (urosepsis), and the forgotten stent that encrusts.

• Urethral catheter

  A tube in the bladder via the urethra. The ED problems: a blocked catheter (painful retention - and in a spinal-injured patient, a hypertensive emergency), bypassing, and a balloon that will not deflate.

Neurological

• CSF shunt (VP shunt)

  A tube draining CSF from the brain's ventricles (usually to the abdomen) for hydrocephalus. The one that kills: a blocked shunt raising intracranial pressure - headache, vomiting, drowsiness - which can progress to coning and death.

• Cochlear implant

  An implanted hearing device with an electrode in the cochlea and a magnet under the scalp. The ED facts: recipients are at higher risk of bacterial meningitis - treat ear infection and meningitis promptly - and diathermy and MRI need precautions.

• Deep brain stimulator (DBS)

  Electrodes in the brain driven by a chest generator, for Parkinson's, tremor or dystonia. The two ways to harm the patient: diathermy (can be fatal) and the wrong MRI - and losing stimulation can trigger a crisis.

• External ventricular / lumbar drain (EVD / LD)

  A temporary tube draining CSF to an external chamber, set to a height above a fixed zero point. The twin dangers: over-drainage if the drain is too low (collapse, bleed) and raised ICP if it blocks - and you clamp it before moving the patient.

• Intrathecal pump (baclofen / drug pump)

  An implanted pump delivering a drug - usually baclofen - into the CSF. The emergency that gets missed: abrupt baclofen withdrawal, which looks like sepsis or an autonomic storm and can kill. Suspect the pump.

• Vagus nerve and spinal cord stimulators

  A chest neurostimulator is not a pacemaker. For a VNS the magnet is the thing to know: hold it on to switch stimulation off, swipe it to give an extra dose.

Other

• Insulin pump and glucose sensor (CGM)

  Two different devices on one patient: a pump that delivers insulin and a sensor that reads glucose. If they are unwell or in DKA, stop the pump and never treat off the sensor alone - confirm on a blood glucose.